GW1--06483_Well Construction - GW1_20231002

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WELL CONSTRUCTION RECORD(GW-I) _. .—. . . ...
- -For Internal U501:W
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, 1.Well Connuctor Information; •
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VIC Contwaxliarni VROM TO
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NC Well Convector Ceoldearion Number ',,15.;0/1TVRCASMd. -ffekeadd.-Potivritiitn91.9RLINERIN.
Morgan Wali,&Pump,INC "FROM, DIAMTiR I TRIMNESS MATERIAL__ -- .-- - --- 0 ft' Sc ft' 61/a 114 I 4d,P21 PVC f
CompayNarne '`16.:124111EICCA AO0RIORENG feeiftrinalebleimiiitiy -;:',:57:;•_-:':.,'•:•.,::.• 7.,:.:.-i.•.,i
2.Well Confined=Permit tis IL/L(9 I PROM TO Dorman THICKNESS M-ATERIAL
7.10411("plicate well conaructiosipermits rig We,estagw.,Asir,;Winger,dm) Ish.
3.Well Use(check well usey
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.11rAticr Supply Wel FROPA1 _TO DIAMETER SLOTSIO_; TDICKPIEss 'r MATERIAL .
1 Agricultural nMtmicipallitblic ft, ft, E.P,
i egotimmgl(41441ins/Cooling Supply) Residential Water Supply(single) fr -----fr.—-10,-,-
1 IndusuialtOoounquial
FROM --rro ofor:Tectuot. . EMI
— NACEMENTMETROD&AMOUNT
MOOR
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Ision-Water--Supply Well: . o fl.• PA ft, ttententte. , POFfed
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•Monitoring EiRecovery ft. f-L7
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X Aquifer Re4bare nerrnmdwata grunge/lotion
ft19•46.111nORAVEACKLgetiOsimbl&n'r:T,?-nt.,r,t1..-:-".--17.:: ,•-.-.•• -: ::-...1-4i. -2-;
.II Aquifer Storage and Recovery n.Salinity Barrier -intim— TO - M4Troloio EMPLACEMENT METHOD
11-MOM!'7.441 OSIESITOVRIft Drainage
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1 Experitnental Technology nSubsidence Control ft, ft,
ft Geothermal(Closed imp) DTP= A.70;11RILLINGWafiRsiliP&OlifibilAgtis If tiPUS4-tIV" .7
FROM - TO DESCRIPTION toltrA-mdtbsis.solliros% t, . Rat,nt.)
I Geothennal(Mau/Cooling Return) nOthcr(explain=ft-#21 Remuks)
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oP-iti'Li-,
&Date Well(s)Completed; - -- Well 1DC _________ 90 IG SO fts 6fokal_ Sri" I
Fa.Wen Locadon: r'' 16 f'' (2/.0(A,A. ' a..__K.i.f-
6 1,3_ I kAltde(5 r ft. rbs ft, 8/ht., 5rciA.A-ed
facility/ Nem Ise*RV(if smolicable) ft- ft. • _ _
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I 46q61 1,01 I/10a i 5it 1 r--..7-- ----,ir-f...-• C 7-•f"'"),
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Physical Addrets.City,sad rip
c:',21:-.2FMARKS -7-..,,.. --...v.•11,:,fi.e. ••,•:-..,.-,i•-.."•••a•;.*.r,...,.:7•-c.•-.: - -: . ...:,-..i.,!.':-.
6101.4 ---"' ' ' . -- ..• ' . Er"ii-2 202-3
County Parcel Identification No,(PIN)
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5b,Latitnds and loutkatle in degreesfininutestsecoods or decimal dmrces; -- - - - -- . -
Orwell field,one Wong is sufficient) 22,Certification; UNC:ISO.G
._ Y9-_.1 0 b _N li• 74140 • W /44 -7-.3
Sipe&ofCcoffied Wen Contmoor- : Date
6.Is(*re)thewell(s)SjPertnanont or OTeraporary
Ay signing Skis form I itervby atiii,liNif AS Uqe•tf(s)Km(wow)enalir#Sfra in=urea=
9.Is this a;repair to au exiS_Iiog well; nYcs or larfo with 154 WACO:x.0mo ar 15A Ne4C1)2C 4020D WO Consultclion Trunclarsis und duo a
If this it a rgpair,,P1 our Amur uull racatrussiou kfunuokus and uspiniu she'tows fsphr MY tirlhis mord bfti b ern Progdgd x Ow wcil mown
main:surer#2I rmaris SSetft112 ar an tlie back of shit form . 23,Site diagram or additional well details;
You may MO dIC ERA of this page to provide additional well sits details or well
3,For GrAprobeff/FP or Closid-Loop Gtotba-mal Virg%having the sgmq
EGIIStmajOtl,only 1 GW-1 is needed, Indicate TOTALNUMBItilt of wells construction details, You may also attach additional pages if TieStgarY.
drilled;I i
gffiMITTAL INSTRUCTIONS :
9,Total well depth below bnd surface: I Cc (ft) 24a, For All WeliM Submit this Rum'within 30 days of completion of well
• 4. Fort:m.10k wits lig ull depths atfferens(ample-302AV god 20100 cftligrftdOft to tbc following,' i
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10.Stade water level below top of Caging; IV _ (k) Division of Water Resources,information Pressing mitt,
fly,r MY few/is abant CtSflOX use"+" 1617 Man Service Center,Roleigh,NC 29699-1617
11,Borebole diameter;6.1/8 (in,) 24b.For Iniedion Wet; In addition tO sending the form to the address in 24n
12,Well cc stetson method; fOtery above,also submit OM copy of this forth Within 30 days of completion of well
_ • __. construction to Me following: -I
(1.4,auger,ret•xy,caw a=pub,;lc) I
- Division of Watir crurces,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Min Service Center,;Raleigh,PIC 29699-.1636
13a,Yield(gpm) Z..' . Method of test;°I'. _ 24e,For Water Sunni)/&injection Welts; In addition to sending the form to
the address(o)above,it submit one copy of this form within 30 days of
13b,piano:own type.;CirA.A4144"tin° Amount: 6, 0 5 0 7.--- completion of well construct', to the county health department of theom
city
—whme consMicted,
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Roo GW-1 North Carolina 1)4r-ot.a of ellitUUMPRI Quality-Division of WaterEmourees i Revised 2-22-2016
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